Acuity and Ratio

[discobunni]

How many pts are you assigned on a daily basis and their acuity level? What is the "standard"? I am wondering because in the NICU I work in, we have had an unusual amount of overflow babies where we have had to open a closed unit. Many nurses have had rather heavy assignments lately, and we have been short on nurses. We have had many instances where Level 2 and 3 babies are mixed together with assignments, and most of the time are left with no charge nurse and no clerk..... we are suppose to "share" with the other unit, but they don't really have time to be of use to us, so we are most of the time left with no supplies, left to scrounge for supplies, restock, put in our own orders, answer the door and phone. Mostly we have feeder grower assignments, but there are always others put into the mix such as babies on IV's, TPN, PICC lines etc.... People started complaining so the manager sent out an email to everyone saying that "4 babies is the standard" and it has been passed around that the director even made a comment that if we kept complaining that everyone was going to start getting 4 baby assignments all the time. Well it seems like that has happened, and it is even worse now because everyone is so tired, noone wants to come in and work any extra shifts to help out. Nurses are starting to turn on eachother because not everything is getting done on the previous shift and it just seems like it is turning into a nightmare. Its like if we bring up what I think are valid points, we get into trouble and they make it worse on us. Plus, there are "clicks" where a select group of nurses get better assignments or a regular basis, such as 2 babies and others will have 4. Can anyone shed some light on what the "NATIONAL STANDARD" is? I'm just wondering where she is getting this information. Thanks for any feed back!!

[RainDreamer, BSN, RN]

Intubate

Surfactant

Extubate

....to nasal CPAP, Vapotherm, HFNC, etc... no ventilation unless required..

That's exactly what we do. We always surf the little ones and then extubate to whatever they tolerate (NCPAP or HFNC).

No one gets surfactant except as a rescue.

Wow, really? It's amazing they make it on NCPAP without being surfed. I personally think surfactant is some good stuff! What's the reason against using surfactant?

[SteveNNP, MSN, NP]

Wow, really? It's amazing they make it on NCPAP without being surfed. I personally think surfactant is some good stuff! What's the reason against using surfactant?

We have a MD (old as dirt) who "invented" bubble cpap back in the 1970s. He's not a neonatologist, or even a peds intensivist. He's an anesthesiologist. Anyway, he has become the unofficial NICU pulmonologist. His theory is that putting babies on NCPAP stimulates the production of surfactant, and conserves it in the alveoli. He considers the risk of surfactant greater than not getting it... so all our pts are placed on NCPAP (the ones that need support) and surfactant is withheld until:

1) severe RDS develops (ummm what did you think would develop? a set of term lungs?)

2) fio2 requirements are >60%

3) Co2 >70mmHg. (also the threshold for intubation)

We do have a pretty decent success rate. Our last study showed a 9% BPD rate. Most babies never get surf, but they all get terrible RDS, a lot of pneumos, and desat and brady for months. (did I mention we hardly use caffeine either? "Side effects" wooooooooo) The ones who get surfed and intubated are the 23-24 weekers. We RARELY have anyone over 26 weeks intubated.

So the nurse is always at the bedside, performing sx/chest PT, repositioning, stimulating, etc. Terrible developmental care.

This same MD is responsible for us having old crappy vents, nasal intubation, no inline sx, and no nasal cannulas. Anyone who needs o2 is on NCPAP.

I personally see a huge amount of NEC here. It's not because we feed early, it's because we allow too high of a Co2, and constant bradys/desats.

I really hope no one other than Elizabells joins this board from my unit. While it's a very prestigious unit, I do NOT agree with the stuff we do. I rarely care for preemies anymore. I ask for cardiac patients, who rarely need the above interventions, and therefore I do not feel the guilt of having my hands tied by this physician who is living in the dark ages.

I will take some valuable lessons about early extubation and aggressive weaning from this place, but that's all. January 2010, and I'm outta here...

[elizabells, BSN, RN]

God, I hope I don't get in trouble for this, but... you know why our BPD rate is so low? Because 21% CPAP doesn't count as an oxygen requirement. How many 3 month old kids do we have still on RA CPAP? Yeah, that's right. Our numbers would be WAY different if that counted.

Doctor Ancient Vent is the same one who is responsible for our abhorrent pain management practices, in case anyone was wondering. Shocking, I know.

I've seen more surf given to PPHN of unknown origin kids than preemies in my time on the unit, btw. Given it x 3 to those kids (once on ECMO! Imagine how fun it was turning that kid about!) and x 1 to a vented preemie.

[SteveNNP, MSN, NP]

Geez, we're just a pair of Negative Nancies tonight, huh?

[elizabells, BSN, RN]

I have to go back to work tomorrow. What's your excuse?

But seriously, I do want to say that our unit is AMAZING at some things. Our CDH survival rates are really high. We do crazy cardiac surgeries. We take kids that even CHOP won't touch sometimes.

And I also want to emphasize that my last comment in NO WAY is trying to imply that our unit is dishonest about our BPD rates. Those are the rules everyone plays by, we don't falsify data or anything shady. It's just that I don't think the criteria for BPD accurately reflect clinical realities. FiO2 requirement does not equal respiratory support requirement.

Thank you, that is all.

[ilstu99]

I have to say that we're pretty flexible on the ratio. The MAX is 1:3, though, even for the feeder/growers.

But, you know, some feeder/growers are a HUGE time and effort compared to others (I mean....I love you, baby N, but you know what I'm talking about there), and some 24-weekers are just hanging out in their boxes and cooking...without any other than their Q6's. So we usually assess ratio needs by infant NEEDS rather than basic status.

We have an RN supervisor and free-floating charge, so if that "stable" 24-weeker goes down the tank, the FFC can take over my feeder/grower until s/he can be reassigned.

At daily rounds, the RN reports the baby's current needs status, and assignments are based on that.